Tag: child neglect

DCFS has lost focus on ensuring the safety and well-being of children as a priority. This is evidenced by several recent cases and the clear lack of attention to assuring children and families receive adequate, thorough, and timely responses and needed services. Investigators, caseworkers and supervisors are unmanaged, and unsupported. Children are dying, children are being left lingering in care, children are being left in in psychiatric hospitals beyond medical necessity causing them to lose hope. This is not just unacceptable it is HARMFUL

That startling statement was made by the Acting Inspector General (IG) for Illinois Department of Children and Families to News Channel 20 about its most recent annual report. During FY 2018, the Office of Inspector General (OIG) reviewed 97 deaths and one serious injury of children whose families were involved in the child welfare system within the preceding 12 months. Of the 98 families involved, at least 52 were the subject of of a completed child abuse or neglect investigation during the previous 12 months; fully 37 of these investigations failed to find any abuse or neglect and were closed without any action to protect the child. Twelve of the 98 families were the subject of an open investigation when the child died, eight were involved in an open family service case, and three had had a family case closed within a year of the death. (See the full count of deaths by case status at the bottom of this article.)

Not all of the deaths or serious injuries can be attributed to DCFS failure to protect a child. Twenty-seven deaths were ruled natural; most of the children involved had serious medical issues. Some of the deaths (including most the 16 youths in foster care)1 were sadly due to violence, car accidents, drug abuse by older youths and other circumstances not under the Department’s control. Heartbreakingly, two older teens in foster care died of abuse that was inflicted on them as infants and left them medically compromised.

However, many of the case reviews suggest DCFS missed danger signs and opportunities to save vulnerable children. Thirteen children were killed by a parent, step parent, parent’s paramour, another relative or unknown perpetrator within a year of an open investigation or service case. These children were beaten, starved, stabbed, and shot to death. The cause of 23 deaths of children in families that recently interacted with DCFS is still undetermined; many are currently being investigated. Most of these children were infants; many of the deaths appeared to be linked to unsafe sleep practices and at least four raised concerns of abuse. The deaths of 24 children with an open or recently open case were classified as accidental. Fourteen of these deaths were attributed to asphyxia, suffocation, or sleep related causes; there were also two accidental drownings, an accidental hanging, and an accidental shooting of a three-year-old by an 11-year-old, as described below.

The OIG completed “full investigations” of four cases that have drawn extensive media attention:

Seventeen-month-old Semaj Crosby was found dead under a couch in her home 30 hours after being reported missing. There was both an open in-home case and a pending child protection investigation of the family at the time Semaj was reported missing. The family had been the subject of 11 investigations during the two years before her death. The mother received SSI for cognitive delays but was never assessed to determine her ability to keep her children safe. Semaj’s seven-year-old brother was psychiatrically hospitalized three times for threatening to kill himself during the time the family’s case was open. A family service caseworker visited the home the day before the toddler was reported missing, and a child protection investigator had been to the house the day the report was made. No immediate safety concerns were reported by this investigator, even though the health department deemed the apartment uninhabitable after the body was found. Criminal and child neglect investigations are pending.

Four-year-old Manual Aguilar was killed, apparently starved to death, and his body was burned post-mortem. Four years before his death, Manual and his three siblings were removed from their mother’s custody after she left the three older children in a car overnight at temperatures hovering around freezing, while Manual was left in a stranger’s care. The children were returned home a year before Manual’s death despite the mother’s failure to progress in therapy and an unfounded investigation stemming from bruises to one child that his older siblings reported were inflicted by the mother during an overnight visit. Five months before Manual’s death, the two older siblings texted to their former foster parent that their mother was beating them, but the investigation was unfounded when they recanted. The mother has been charged with murder.

A daycare center reported that a two-and-a-half-year-old appeared to have cigarette burns on both hands. The reporter also said the child’s face had been swollen on two prior occasions, and an unknown male accompanying the mother was seen to hit the child across the face a week before. The investigator closed the case without investigating adequately either the child’s burns or the family’s allegation that they occurred at the daycare. Two days following the investigation’s closure, the child experienced cardiac arrest and died four days later. The autopsy concluded that the manner of death was undetermined and suspicious, but a child protection investigation did not find evidence to find anyone responsible for the death.

An eleven-year-old girl accidentally shot her three-year-old brother in the head while playing at home. This child survived and and this appears to be the only non-fatal case reviewed. The parents had left four of their children, of which the eleven-year-old was the oldest, at home alone. The father had eight drug convictions and had been arrested multiple times for physically assaulting the mother. The investigation of the shooting was the eleventh investigation of this family since 2008. One investigation had occurred when the father barricaded himself in the home with the mother, who was eight months pregnant, and the screaming and crying children. The children’s eight-year-old sibling was in residential care in the custody of DCFS at the time of the shooting and the agency was required to monitor the at-home siblings as well. Nevertheless no visits by case managers to the home were documented in the 45 months before the shooting with one exception. A case manager attempted to visit the home 21 days before the shooting but was not allowed in. .

The acting Inspector General told a reporter that understaffing may have contributed to the state’s inability to prevent child deaths. Following the death of Semaj Crosby, the OIG investigated a media report that child protection workers in the local office were offered incentives for early case closure. The IG found that while Semaj’s family was involved with DCFS, the entire region was understaffed (at times as low as 66% of staff needed), resulting in excessive caseloads for investigators. In December 2016, the field office administrator offered a $100 gift card to the investigator who could close the most cases in January. The IG found similar incentive programs for early case closure around the state.

The OIG also found that “a large contributing factor to the caseload problem was that the previous director had several management initiatives that seemed to take priority” over any attempt to redistribute caseloads. One of these initiatives, Rapid Safety Feedback, received some media attention last year. DCFS awarded a multimillion-dollar contract to two out-of-state firms using a “propriety algorithm to identify cases most likely to result in death or serious injury.” There were concerns that this contract was one of several no-bid contracts given to a circle of former associates of the previous director, as described by the Chicago Tribune. The contract was terminated after 25 to 50 percent of cases were flagged as having a a greater than 90% probability of death or serious injury in the next two years, alarming and overwhelming social workers. At the same time, the algorithm failed to predict the death of Semaj Crosby and other children who were killed while under supervision by DCFS.

The OIG report identified two areas of “chronic misfeasance,” or conduct that is lawful but inappropriate or incorrect. One of these areas is “intact family services,” which is DCFS-speak for the services provided to families to prevent further abuse or neglect without removing the child. OIG’s 2018 annual report included an eight-year retrospective on the deaths of children in intact family services cases. The OIG concluded that in many of these cases the children remained in danger during the life of the case due to violence in their homes, when DCFS should have either removed the children or at least sought court involvement to enforce participation in services.

A second area of “chronic misfeasance” identified in the 2019 report which has also drawn media coverage is the practice of leaving foster children in psychiatric hospitals “beyond medical necessity,” or after they are stable enough to be cared for outside that setting because there is no appropriate placement. OIG reported that the number of such episodes increased from 273 in FY 2017 to 329 in 2018. “The availability of community-based services and resources for youth with significant mental and behavioral needs continues to be at crisis levels.”

The OIG’s overall conclusion–that child safety and well-being are no longer priorities for DCFS–is sobering. But even more alarming is the fact that this description could be applied to many or even most other states. Although we don’t have numbers for most states, every year brings stories from around the country of children killed after long histories of contact with child welfare authorities. Twenty-seven percent of the fatality cases analyzed by the Administration on Children and Families for its Child Maltreatment report had at least one Child Protective Services contact within the past three years. State child welfare agencies tend to hide behind strict privacy protections in order to avoid releasing information on child protection failures, even though the case information could be released without including the names of the families involved. As a member of the District of Columbia’s Child Fatality Review Commission, I hear at almost every monthly meeting about one or more children who died after the family was called to the attention of CPS multiple times. And yet, I am not allowed to share any information about these cases with anyone, including legislators.

At least in Illinois, thanks to the DCFS Inspector General, the public and its elected representatives are given the opportunity to learn about failures to protect children while in the custody of their parents as well as those the custody of DCFS. This information helps make the case for change. The OIG report was the subject of a hearing in Springfield. The Governor has already requested an increase of more than $70 million for 126 new staff and technology upgrades.

Unfortunately, most states do not have an independent agency like the Illinois OIG to look out for children who are served by the agency both at home and in care. In a report issued on April 4, 2018, the National Council of State Legislators found that only 11 states have “an independent and autonomous agencies with oversight specific to child welfare,” although they seem to have missed Illinois. All states need such an autonomous agency. Somebody needs to reveal the truth about how we fail our most vulnerable children–and what it would take to do better.

Number of Child Deaths by Case Status from OIG Report

Case Status*Number of deaths or serious injuries

Pending Investigation at time of child’s death………………………………………………………12

Unfounded Investigation** within a year of child’s death……………………………………37

“Indicated” Investigation*** within a year of child’s death…………………………………..15

Youth in care………………………………………………………………………………………………………………16

Open Placement/Split custody****……………………………………………………………………………..3

Open Intact Case*****………………………………………………………………………………………………….8

Closed Intact Case within a year of child’s death……………………………………………………….3

Preventive services to assist family but not as result of indicated investigation………1

Total……………………………………………………………………………………………………………………………….98

*When more than one reason existed for the OIG investigation, the death was categorized based on “primary reason.”

**An investigation in which the agency was unable to verify that abuse or neglect occurred.

***An investigation in which abuse or neglect by the parent was found to have occurred.

****Child was in home with siblings in foster care

****A case in which the family was receiving services while the child remained in the home.

Of the 16 children who died while in foster care, a 14-year-old and an 18-year-old died of gunshots by unrelated perpetrators, two died as a consequence of abuse by their parents in infancy, three were infants in care of relatives and cause of death was undetermined for two and suffocation for one, two died of methadone or opioid intoxication, one 18-year-old died in a car accident and five died of natural causes. ↩

I recently read a book that should be a must-read for all involved in child welfare policy. In Etched in Sand, Regina Calcaterra tells of being left at the age of eleven to care for her two younger siblings while her mother disappeared for weeks at a time. When she was home, her mother savagely beat the children. Chronically malnourished and living in fear, Calcaterra was responsible for feeding, clothing, and protecting her younger siblings–and making sure they looked clean and well-fed so as not to draw the attention of the authorities who might place them in foster care.

Despite her horrific childhood, the goal of Regina and her older siblings, as she said in an interview for Youtube TV, “was to never to be picked up by the authorities because when the authorities found out how we were living, they would separate us.” When Regina was finally unable to satisfactorily explain the results of a savage beating, the children were indeed taken into care and separated.

No maltreated children should have to hide their plight in order to avoid separation from each other. Yet, this is undoubtedly the situation facing many children even while you read this. I myself know two girls who, for fear of being separated, remained for two years with an uncaring guardian who diverted her guardianship stipend to her own needs. The girls only recently broke the silence, and were removed from this toxic home.

Sibling relationships are known to be critically important in emotional development in childhood and beyond, as documented in a useful publication from the Child Welfare Information Gateway. In abusive and neglectful families, sibling relationships can be even more important as siblings support each other through adverse circumstances.

Keeping siblings together in foster care provides an important element of continuity for children who have already suffered a traumatic removal from the home they had known. As the the brief cited above puts it, “For children entering care, being with their brothers and sisters promotes a sense of safety and well-being, and being separated from them can trigger grief and anxiety.” Some studies have reported poorer outcomes for children separated from their siblings in foster care.

We don’t know how many siblings are separated in foster care. Older studies indicate that a large proportion of foster children were separated from at least some of their siblings, but the proportions varied by location. Current, national data are not available.

In most cases siblings are separated for no other reason than the lack of foster homes that can accommodate siblings, especially larger sibling groups. There is a nationwide shortage of foster parents, but foster parents who are able to take more than two siblings are even more scarce.

In some states, like North Carolina and Florida, family-style group homes have been an important vehicle for keeping siblings together. Many of these homes, such as Crossnore School and Children’s Home in North Carolina and A Kid’s Place in Florida provide highly enriched services to their residents with the help of public and private philanthropic funding. These homes often use a family-style model based on houseparents that mimics a family home. Group homes are serving sibling groups in many other states, including California, Texas and New York.

Unfortunately, the recently passed Family First Prevention Services Act (FFPSA) threatens these important havens for sibling groups and may result in mass separations of siblings. That’s because FFPSA eliminates federal funding for placement of children in congregate-care settings such as group homes beyond two weeks, unless an assessment shows that a child’s needs cannot be met with family members or in a foster family home. Moreover, group facilities must meet criteria as “Qualified Residential Treatment Programs” designed to meet the needs of “children with serious emotional or behavioral disorders.”

FFPSA is based on the widely-held belief in child welfare circles that most children do better in a family than in another type of setting. However, experts such as Dave Bundy, President and CEO of the Children’s Home Society of America, believe that it is better to keep siblings together in congregate care than to split them up among separate foster homes.

Moreover, many legislators and executives pressing for closing group homes have much more than children’s best interests at heart. The greater cost of congregate care has clearly contributed to its growing unpopularity and to the bipartisan support of FFPSA. But these comparisons are often deceptive. Facilities like Crossnore and the Florida Sheriffs Youth Ranches provide therapists, case managers, after-school activities, and other services, such as therapeutic riding. Moreover, they bring in substantial private funding in addition to state support. And no matter how expensive they are, they cannot cost more than keeping children in hotels and offices when there are no homes for them, which is happening around the country.

Siblings have already been separated due to the policies against congregate care that have already taken hold in some states. From 2006 to 2015, Sonoma County Children’s Village was a haven for 24 foster children, including sibling groups, who lived in four homes staffed by “village parents,” with surrogate grandparents living in onsite apartments. But after California began to limit group home placements for children requiring high levels of care, the village had to close. Sixteen children, including a group of seven siblings, had to leave. The children were devastated. They sent out appeals to the likes of Barack Obama and Taylor Swift, but to no avail.

There is another approach to housing large sibling groups which in practice looks very similar to family-style group homes. Some child welfare agencies contract with private agencies, such as Neighbor to Family in Florida and Georgia, that provide homes where siblings can live together in foster care. Some of these programs actually provide larger houses in clusters or “neighborhoods” to foster parents willing to care for large sibling groups but who don’t have the space. This clustering provides the added benefit of community support and shared facilities for recreation and other activities. Such programs include the SOS Children’s Villages in Illinois and Florida. New homes are currently being built in locations around the country including Oklahoma, and Southwest Florida. However these programs are too few and far between to make a dent on the national problem of sibling separation in foster care.

Perhaps all the group homes that keep siblings together could eventually be replaced by family foster homes with housing provided by public and private agencies. The feasibility of this approach would have to be investigated; it might be even harder to find good foster parents than it is to find good houseparents, because the latter generally have a schedule that allows time off to return to their own residences, while being replaced by a substitute couple. In any case, such a transition would take years to accomplish and could not occur in the short period preceding the implementation of the FFPSA provisions, which go into effect on October 1, 2019. States can apply for a two-year delay in implementing these provisions but then they must forego the opportunity to received federal matching funds for services to prevent foster care placements. (For a detailed explanation, see the “Cliffs’ Notes on Family First” from the Chronicle of Social Change.)

The sponsors and supporters of FFPSA likely had no idea that sibling separation might be a consequence of their legislation. Once they understand what they have done, I hope they will consider amending FFPSA to make congregate care allowable for sibling groups and provide a new funding stream to encourage jurisdictions to build foster home communities where siblings can thrive together.

As a field, child welfare seems to be particularly vulnerable to myths and misconceptions, which are often backed up by inaccurate interpretations of research. Unfortunately, these myths and misconceptions, when promoted by powerful and wealthy advocates, can be perpetuated and enshrined into policy. This is the beginning of an occasional series in which I attempt to deconstruct some of the most common myths. We start with one of the most common and potentially destructive–the myth that children left with their families always do better than they would if placed in foster care.

This myth was recently exhibited in all its glory by the Arizona Star as part of a major series on child welfare in that state. Here is how reporter Emily Bregel describes a frequently quoted study.

Research indicates that children left with their own troubled families fare better than those brought into the foster care system. A 2007 study found children whose families were investigated for abuse and neglect but remained home were less likely to become teenage parents or juvenile delinquents than similarly abused children who were removed from home. Those left at home were also more likely to have jobs as young adults, compared with children of similar backgrounds who were put in foster care.

This oft-misquoted study was published by Massachusetts Institute of Technology’s Joseph Doyle in 2007. Doyle’s study has been used relentlessly–and often inappropriately–by advocates of reducing foster care placements. Doyle used a creative method to estimate the effects of foster care on Illinois children ages 5 to 15 who were receiving welfare and who were investigated for maltreatment for the first time between July 1, 1990 and June 31, 1991. He compared long-term outcomes (delinquency, teen motherhood, and employment) for the children assigned to investigators with higher removal rates to outcomes for those assigned to investigators with lower removal rates.

By comparing the outcomes for the two groups, Doyle could estimate the effects of being placed in foster care for children who were on the margin of placement–those who might have been placed by one investigator and not by another. For those children, Doyle found large differences favoring those children who were not removed from their homes. Doyle’s results say nothing about the children whose cases were unambiguous and who would have been placed (or not placed) regardless of the investigator.1

Obviously, we cannot do a controlled experiment in which the same child is both placed and not placed in foster care to get at the true difference that it makes in children’s lives. Perhaps the best we can do is ask the children themselves. Researchers at the University of Chicago’s ChapinHall research center surveyed 727 sixteen and seventeen year olds who had in foster care in California for at least six months. When asked about their treatment by their parents or other caregivers before entering foster care, 36% reported that they were hit hard with a fist, kicked or slapped; 32.4% reported that a caregiver threw or pushed them; 28.4% reported missing school to do chores or care for a family member; 28.3% reported having to go without things they needed because the parent’s paycheck was spent on “adult interests,” 26.4% reported that their caregiver beat them up; and 24.9% reported that their caregiver failed to protect them from harm by someone else. A shocking 29.7% reported sexual molestation and 20.7% reported rape. Horribly, 18.6% reported that their caregiver tried to choke, smother or strangle them and 16.9% reported being locked in a closet or room for several hours or longer.

When asked about characteristics of the parent or caregiver they lived with before entering foster care, 48.8% reported inadequate parenting skills, 49.7% a criminal record, 48.3% drug abuse, 48.8 alcohol abuse, 33% reported that a caregiver was abused by or abused a spouse or partner and 25.6% said a caregiver had mental illness. In addition, a total of 56.9% reported that they either agreed, strongly agreed or very strongly agreed with the statement, “All in all I was lucky to be placed in the foster care system,” while only 17.6% disagreed.

The California survey suggests that more often than not, foster care is an improvement over families where children are unsafe, fearful, hungry, unsupervised, or unloved. However, I have learned from my own experience as a social worker that, while some children make the miraculous journey from hell to heaven when they are placed in the best foster homes, many foster homes are only slightly less chaotic and more nurturing than the homes from which the children have been plucked. The beatings, rapes, and hunger may be over but many children and youth continue to be neglected emotionally, educationally, and in other ways in foster care. When combined with the trauma caused by separation from family, it is not surprising that young people whose home lives were on the border between acceptable and unacceptable to an investigator may do worse in foster care than they would have done at home.

Neglect of children in foster care is inexcusable: these children need more than the usual nurturing in order to make up for the trauma and deprivation they may have already suffered in their birth homes. That’s why we need to increase the number of children placed with kin as well as other alternatives to traditional foster care, such as residential schools and hybrid arrangements that combine features of foster and group homes. But what we don’t need to do is abandon children in homes where they are not safe.

The misuse of Doyle’s article has supported the ideas that it is always better to reduce the number of children in foster care and that reduced care numbers are a prima facie indicator of improvement. It has led to many systems, like that of my home town of Washington DC, using reduction of foster care numbers as an outcome in itself–independent of trends in actual maltreatment. Using foster care reduction as an indicator of success fails to recognize that some placements are needed to keep children safe. It also means that jurisdiction, like New York City for example, may be claiming partial credit for the results of gentrification.

The misuse of research and data, especially when translated into policy, should disturb everyone regardless of their feelings about the particular issue. Doyle’s research suggests that when the case for removal is marginal, the default option might be to keep the child at home–with supervision and services by the state. It does not suggest that removal of a child from home is always the wrong decision or that programs should be rated solely on the ability to cut foster care rolls.

Another problem with making inferences from Doyle’s study about foster care today is the age of his data, which are from 1990 and 1991. Child welfare culture and practices have changed greatly since that time and the relevance of research from 25 years ago is questionable. ↩

A new book by two leading child welfare researchers aims to elucidate the complex world of child welfare for the general public and policymakers. In After the Cradle Falls, Melissa Jonson-Reid and Brett Drake of Washington University provide a useful primer for the child welfare field. While they may be overly optimistic in assuming that a lay audience will pick up this book, it will certainly be useful for policymakers, journalists, students and advocates who want a general overview of child abuse and neglect, child welfare systems, and proposals for change.

Jonson-Reid and Drake make a particularly valuable contribution by highlighting myths and common misconceptions that are rife in the child welfare field. Among the common myths they debunk are the following:

“Neglect” is just another word for poverty, and parents become embroiled with Child Protective Services just because they are poor. Johnson-Reid and Blake explain that while poverty increases the risk of neglect, most parents who are poor do not neglect their children. Neglect is much more serious than a missed dental appointment or a messy house. Some neglect cases are extremely severe, even fatal. But even less severe cases can result in devastating lifetime consequences on brain development and the ability to form relationships.

Racial disproportionality in child welfare involvement is caused by racist decision-making by Child Protective Services (CPS). There is no dispute that African-American children are overrepresented in child welfare services and foster care compared to their share of the population. But Jonson-Reid and Drake conclude that “it is hard to find current empirical data that suggest that widespread bias within today’s CPS system is a significant driver of current disproportionality.” It would have helped if they had included the key research finding that actually debunked the myth about racism and disproportionality. As I have explained elsewhere, research has conclusively shown that higher Black representation in the child welfare system reflects higher rates of maltreatment in African-American families. This Black/White maltreatment gap may in turn reflect the relationship between race and poverty, as Jonson-Reid and Drake suggest.

State and local agencies have an incentive to take more kids into foster care. This trope was mentioned over and over again by supporters of the Family First and Prevention Services Act (FFPSA), which was signed into law on February 9, 2018. Jonson-Reid and Drake rightly give it short shrift. They explain that states are required to make “reasonable efforts” to keep children with their families and can be sanctioned by the federal government if they fail to document that they have made such efforts. The authors could have cited some other key evidence against this myth. For example, only about half of children in foster care are eligible for federal foster care support under Title IV-E of the Social Security Act and the federal government pays only part (50 to 83% depending on the state) of the cost. States and localities spent about $8 billion on foster care in FY 2014, 47% of their total child welfare spending, so it is hard to understand how they could have an incentive to place children in foster care. Moreover, states have access to other federal funds for services to intact families, such as TANF, Title IV-B, and the Social Services Block Grant.

Child welfare systems should prevent abuse and neglect. As the authors point out, child welfare systems (which they refer to as CPS, a term that I prefer to reserve for the investigation function only) have no truly preventative role. They are charged with responding to abuse and neglect after they have already occurred. This common misconception is particularly important in relation to the recent debate on FFPSA. Despite its name, the Act does not fund prevention; rather it funds treatment, or services to parents who have already maltreated their children. Obscuring the distinction between prevention and treatment prevents an honest and clear-headed debate about the appropriate allocation of resources between these purposes.

Child welfare is a broken system: Jonson-Reid and Drake argue that rather than being broken, the child welfare system has never been completed. They compare it to a fire department that will will send out a fire truck only 60% of the time, and often after the house has been consumed by flames. When a truck does respond, the firefighters may have minimal training in firefighting. A firefighter might show up without a truck and will have to wait until a truck with water is found. An injured person, instead of being taken into a hospital, may be placed in the home of someone who has no idea what treatment they need.

Child welfare can be fixed in a cost-neutral manner. Jonson-Reid and Drake point out that reform efforts (such as privatization or differential response) have often aimed to do more with less or the same amount of resources and have thus either done harm or failed to make a difference. They argue that any real improvement would raise costs but but could result in big long-run savings. They point out that we spend only $30 billion a year on child welfare when the long-term costs of child maltreatment have been estimated at $250 to $500 billion for each year’s cohort of victims.

The last myth is particularly poignant in view of the recent passage of FFPSA. It expands the use of federal Title IV-E funds to services to parents at risk of losing their children to foster care. But it finances some of this new spending by taking money from other key functions of child welfare. like congregate care placements (necessary both for therapeutic reasons and to make up for the foster parent shortage), and foster care payments to kin, who will now not be allowed these payments if the parent is receiving federally-funded services.

Jonson-Reid and Drake end with an extensive list of suggestions for changing programming, policy and law. These include primary (or universal) prevention such as poverty reduction and educating parents about positive parenting, systemic improvements to child welfare (such as completing the system), and improving and expanding treatment for children and families. The list is somewhat overwhelming, but gives policymakers and advocates many options for where to start addressing this massive and complex problem.

After the Cradle Falls is a realistic and informed discussion of child welfare. It will be a useful resource to those who are open minded enough to accept the conclusions of science and common sense even when they conflict with the facile platitudes of ideologues, which have all too often had a disproportionate influence on policy and practice.

“A system should not be judged by one case, no matter how sad or sensational,” said Joette Katz, Commissioner of Connecticut Department of Children and Families (DCF) Katz’ words were reported by the Hartford Courant.

Katz was referring to the case of Matthew Tirado. Matthew, a 17-year-old diagnosed with Autism and Intellectual Disability, died on February 14, 2017 from prolonged abuse and neglect by his mother. As revealed by a heartbreaking report from Connecticut’s Office of the Child Advocate (OCA), Matthew had been known to DCF for 11 years, since he was five years old. Yet, DCF missed several opportunities to save Matthew, who was nonverbal and could not speak for himself. Matthew’s interactions with DCF included:

In December 2005, when Matthew was six years old, his school called DCF to report that Matthew had missed more than 30 days of school since the school year began, . DCF investigated and found neglect but later closed the case after Matthew’s attendance briefly improved.

In December 2006, the school again contacted DCF to report that Matthew had missed over 50 days of school. DCF closed the case six weeks later without finding neglect. Matthew’s mother told DCF that her mother was moving in to help her care for the children. This should have been a red flag because agency files documented Matthew’s grandmother’s long history of involvement with DCF, alcohol abuse and mental illness. But repeated risk assessments erroneously noted that Matthew’s mother had no history of being abused or neglected as a child.

In 2009, school officials again called CPS stating that Matthew came to school with bruising on his face that was covered up with makeup. School officials also reported contacting Ms. Tirado on other occasions regarding bruises, which she responded were inflicted by Matthew’s two-year-old sister. Matthew’s mother denied abusing him and the case was closed before requested medical records arrived.

In October, 2014, Hartford Public Schools (HPS) reported that Matthew’s sister, a first-grader, showed signs of physical abuse and reported that her mother hit her. She told school staff that Matthew was also hit, but he was not seen or assessed.

In November 2014, HPS reported to DCF that Matthew was not enrolled in school and may not have been in school for a long time. In fact, Matthew had hardly attended school since 2012. DCF found Ms. TIrado to be neglectful and abusive and opened a case on the family for supervision by the agency.

Matthew attended less than 100 days of school between June 2012 and his death in February 2017. HPS made five reports to DCF between October 2014 and May 2016. about the children’s failure to attend school. After March 2016, Ms. Tirado refused to allow DCF access to her children. In July, DCS iled a neglect petition with the Juvenile Court.

The Court held six hearings on the case between July and December 2016 but Ms. Tirado never appeared. In December 2016 DCS asked the court to terminate the case. No orders were sought to compel Ms. Tirado to produce the children, permit visitation of Matthew’s sister in school, or to remove the children, even though there was legal justification for any of these actions. Unbelievably, after a failed attempt to compel Ms. Tirado to come to court, the court accepted DCS’ request to close the case. DCS closed its own case on the family in January 2017.

After Matthew’s death, the Hartford Courant reported that Commissioner Katz shockingly told legislators that “As horrible as this may sound, there comes a point where you have to make a determination that you have done all that you can legally do. There are 15,000 cases and only so many social workers.”

The Commissioner also said that a system should not be judged based on one case. It’s an old refrain. But is it true? I don’t think so. There are many reasons why a system should be judged by one case.

First, we are not talking about one bad decision. A child suffered for as long as 11 years and agency social workers missed multiple opportunities to protect him. His sister fared a little better since she survived but will probably bear lifetime scars. This is more than a one-time event.

Secondly, for each “worst case, “we don’t know how many children suffer for years and don’t die while the system ignores repeated red flags. At least Matthew is out of his misery. The others are still suffering. We may never know their names.

I’m tired of agency heads who tell us not to judge the system by the worst cases. Lets bury this trope once and for all. A system should be judged–above all–by the worst cases. For each of these cases represents many more children whose daily suffering will lead to lifetime emotional educational and physical damage.